5.1 Pharmacotherapy of depression

Question 1

What is the risk of recurrence after a subsequent episode(s)?

Answer 1

• After 1 episode: 50-60%
• After 2 episodes: 70%
• After 3 episodes: 90%

Question 2

What is the definition of remission for depression?

Answer 2

A period of 2 or more months w no sxs or only 1-2 minimal sxs

Question 3

When does the risk of recurrence get lower?

Answer 3

Risk becomes lower over time as duration of remission increases

Question 4

What is a predictor of recurrence?

Answer 4

Persistent mild sxs during remission

Question 5

When does function get worse and better?

Answer 5

Function deteriorates during the episode and goes back to baseline upon remission

Question 6

According to the DSM5, what is the diagnostic criteria for depression?

Answer 6

At least one of the sxs must be depressed mood or loss of interest or pleasure in doing things

Question 7

What is the mnemonic for the DSM5’s diagnostic criteria sxs for depression?

Answer 7

SIGE CAPS:
- Sleep (insomnia/hypersomnia)
- Interest decreased (anhedonia)
- Guilt/worthlessness
- Energy loss/fatigue
- Concentration difficulties
- Appetite change (increase or decrease)
- Psychomotor agitation/retardation
- Suicidal ideation

Question 8

What setting was the PHQ9 developed for?

Answer 8

Developed for the primary care setting

Question 9

What is PHQ9 used for?

Answer 9

Used repeatedly to determine efficacy and treatment

Question 10

What does the PHQ9 scores of 5, 10, 15, and 20 correspond to?

Answer 10

• 5: minimal
• 10: mild
• 15: moderately severe
• 20: severe

Question 11

What setting was the quick inventory of depressive symptomatology self-report (QIDS-SR-16) developed for?

Answer 11

Developed for psychiatric practice

Question 12

What does the QIDS-SR-16 focus on?

Answer 12

Focuses on 16 diagnostic sxs

Question 13

What does the QIDS-SR-16 scores of <=5, 6-10, 11-15, 16-20, and >= 21 correspond to?

Answer 13

• <=5: normal
• 6-10: mild
• 11-15: moderate
• 16-20: moderately severe
• > =21: severe

Question 14

What can the MDQ be used for?

Answer 14

Can be used to rule out bipolar disorder

Question 15

What does the MDQ consist of?

Answer 15

5 question assessment

Question 16

What is a positive score for bipolar disorder on the MDQ?

Answer 16

> = 7 yes responses

Question 17

What are the goals of tx for depression?

Answer 17

• 1: reduce or eliminate s/sxs of depression
• 2: restore occupational and psychosocial functioning to baseline
• 3: reduce the risk of relapse and recurrence
• 4: reduce the risk of harmful consequences (suicidal ideation)

Question 18

How do you choose the pharmacotherapy?

Answer 18

• Pt preference
• Prior medication response
• Safety, tolerability, SEs
• Co-occurring psychiatric and medical conditions
• Pharmacologic properties
• Cost

Question 19

What are the phases of depression tx?

Answer 19

• Acute
• Continuation
• Maintenance

Question 20

What does the acute phase of tx consist of?

Answer 20

• 6-12 weeks or remission of sxs
• Goal: induce remission

Question 21

What does the continuation phase of tx consist of?

Answer 21

• 4-9 additional months, recommended for all pts
• Goal: prevent relapse

Question 22

What does the maintenance phase of tx consist of?

Answer 22

• Pt-specific duration
• Often indefinite tx if >= 3 major depressive episodes
• Goal: prevent recurrence

Question 23

What is the boxed warning for all antidepressant medications?

Answer 23

Boxed warning for suicidality in ALL antidepressant meds (for pts aged <= 24 yo)

Question 24

What is required w MAOis?

Answer 24

Tyramine diet

Question 25

Why is a tyramine restricted diet required w MAOis?

Answer 25

Tyramine is degraded by monoamine oxidase –> MAOis inhibit monoamine oxidase –> increase in tyramine increases BP

Question 26

What is included in the tyramine diet?

Answer 26

• Smoked, aged, pickled meats or fish
• Sauerkraut
• Aged cheeses
• Yeast extracts
• Flava beans
• Beer and wine

Question 27

What can happen if MAOi is not taken w a tyramine restricted diet?

Answer 27

Hypertensive crisis

Question 28

What is the mechanism of Bupropion (Wellbutrin)?

Answer 28

• Dopamine and norepinephrine reuptake inhibitor (DNRI)
• Stimulating: insomnia and appetite suppression

Question 29

What is the dosing of bupropion (wellbutrin)?

Answer 29

SR/XL dosing: 150-450 mg/day

Question 30

What are clinical pearls of bupropion (wellbutrin)?

Answer 30

• 2D6 inhibitor
• CI in active seizure disorder and eating disorders
• Can be used in combination w SSRI/SNRIs

Question 31

What is the dosing of Mirtazapine (Remeron)?

Answer 31

Sedation and increased appetite occur w doses <= 15 mg/day

Question 32

What are AEs of mirtazapine (remeron)?

Answer 32

• Warnings: agranulocytosis, increased cholesterol
• Can be used in combination w SSRI/SNRIs

Question 33

What is the mechanism of trazodone (desyrel)?

Answer 33

Selectively inhibits neuronal reuptake of serotonin and acts as an antagonist at 5HT1, 5HT2, H1, and alpha1

Question 34

What is a dosing pearl of trazodone (desyrel)?

Answer 34

Higher doses needed for depression

Question 35

What are the SEs of trazodone (desyrel)?

Answer 35

• Orthostatic hypotension
• risk of priapism: medical emergency

Question 36

What is the mechanism of vilazodone (viibryd)?

Answer 36

• Primarily SSRI, may have some 5HT1A agonism which may provide anxiolytic effects
• DO NOT USE in combination w SSRI/SNRIs

Question 37

What are clinical pearls of vilazodone (viibryd)?

Answer 37

• 3A4 substrate
• Nausea
  Take w food:
• Significant nausea
• Bioavailability increases w food

Question 38

What is the tx for serotonin syndrome?

Answer 38

• Stop the offending agent + supportive care
• Potentially could use serotonin blockers (cyproheptadine –> variable efficacy)
• 70% of pts recover within 24h

Question 39

What can cause antidepressant withdrawal syndrome?

Answer 39

• Common w ALL antidepressants EXCEPT fluoxetine
• Abrupt discontinuation can lead to it

Question 40

What should be tapered no matter what?

Answer 40

Antidepressants w anticholinergic activity

Question 41

What are the FDA approved augmentation agents?

Answer 41

Atypical antipsychotics:
- Aripiprazole (Abilify): 2-15 mg/day
- Brexipiprazole (Rexulti): 0.5-3 mg/day
- Cariprazine (Vraylar): 1.5-3 mg/day
- Quetiapine (Seroquel): 50-300 mg/day

Question 42

What are the non-pharmacologic tx options for depression?

Answer 42

• Psychotherapy
• Electroconvulsive therapy (ECT)
• Vagus nerve stimulation (VNS)
• Transcranial magnetic stimulation (TMS)